Spiral computed tomography for the diagnosis of acute pulmonary embolism

Paul D. Stein; Fadi Kayali; Russell D. Hull

doi:10.1160/TH07-03-0218

Thrombosis and Haemostasis, Inhaltsverzeichnis

Thromb Haemost 2007; 98(04): 713-720
DOI: 10.1160/TH07-03-0218

Review Article

Schattauer GmbH

Spiral computed tomography for the diagnosis of acute pulmonary embolism

Paul D. Stein

¹St. Joseph Mercy Oakland Hospital, Pontiac, Michigan, USA

²Department of Medicine, Wayne State University, School of Medicine, Detroit, Michigan, USA

,

Fadi Kayali

¹St. Joseph Mercy Oakland Hospital, Pontiac, Michigan, USA

,

Russell D. Hull

³University of Calgary, Calgary, Alberta, Canada

› Institutsangaben

Abstract

Summary

The accuracy of computed tomography (CT) imaging for the diagnosis of acute pulmonary embolism (PE) was reviewed. Single detector CT, based on pooled data, showed a sensitivity of 73% and multidetector CT, mostly 4-slice, showed a sensitivity of 83%. Respective specificities were 87% and 96%. Among patients with suspected PE evaluated with single slice CT,20% of patients found to have venous thromboembolic disease were diagnosed on the basis of a positive CT venous phase venogram. With multislice CT, 14% were diagnosed on the basis of a positive CT venogram.The positive likelihood ratio with single detector CT was 5.7 and with multidetector CT it was 19.6. Respective negative likelihood ratios were 0.31 and 0.18. Calculations of post-test probability using pretest probability and likelihood ratios according to Bayes’ theorem showed that even with multidetector CT, false positive and false negative images are not uncommon when clinical assessment is discordant with the CT interpretation. Outcome studies showed recurrent PE in only 1.7% or fewer untreated patients with negative CT pulmonary angiograms.

Keywords

Pulmonary embolism - deep venous thrombosis - venous thromboembolism - computed tomography

Volltext

Referenzen

References
1 Remy-Jardin M, Remy J, Wattinne L. et al. Central pulmonary thromboembolism: diagnosis with spiral volumetric CT with the single-breath-hold technique-- comparison with pulmonary angiography.. Radiology 1992; 185: 381-387.
2 Lijmer JG, Mol BW, Heisterkamp S. et al. Empirical evidence of design-related bias in studies of diagnostic tests.. J Am Med Assoc 1999; 282: 1061-1066.
3 Qanadli SD, Hajjam ME, Mesurolle B. et al. Pulmonary embolism: prospective evaluation of dual-section helical CT versus selective pulmonary arteriography n 157 patients.. Radiology 2000; 217: 447-455.
4 Drucker EA, Rivitz SM, Shepard JA. et al. Acute pulmonary embolism: assessment of helical CT for diagnosis.. Radiology 1998; 209: 235-241.
5 Nilsson T, Soderberg M, Lundqvist G. et al. A comparison of spiral computed tomography and latex agglutination D-dimer assay in acute pulmonary embolism using pulmonary arteriography as gold standard.. Scand Cardiovasc J 2002; 36: 373-377.
6 Perrier A, Howarth N, Didier D. et al. Performance of helical computed tomography in unselected outpatients with suspected pulmonary embolism.. Ann Intern Med 2001; 135: 88-97.
7 Remy-Jardin M, Remy J, Deschildre F. et al. Diagnosis of pulmonary embolism with spiral CT: comparison with pulmonary angiography and scintigraphy.. Radiology 1996; 200: 699-706.
8 Ruiz Y, Caballero P, Caniego JL. et al. Prospective comparison of helical CT with angiography in pulmonary embolism: global and selective vascular territory analysis. Interobserver agreement.. Eur Radiol 2003; 13: 823-829.
9 Van Strijen MJ, De Monye W, Kieft GJ. et al. Accuracy of single-detector spiral CT in the diagnosis of pulmonary embolism: a prospective multicenter cohort study of consecutive patients with abnormal perfusion scintigraphy.. J Thromb Haemost 2005; 3: 17-25.
10 Stein PD, Fowler SE, Goodman LR. et al. Multidetector computed tomography for acute pulmonary embolism.. N Engl J Med 2006; 354: 2317-2327.
11 Schoepf UJ, Holzknecht N, Helmberger TK. et al. Subsegmental pulmonary emboli: improved detection with thin-collimation multi-detector row spiral CT.. Radiology 2002; 222: 483-490.
12 Remy-Jardin M, Remy J, Artaud D. et al. Peripheral pulmonary arteries: optimization of the spiral CT acquisition protocol.. Radiology 1997; 204: 157-163.
13 Goodman LR, Curtin JJ, Mewissen MW. et al. Detection of pulmonary embolism in patients with unresolved clinical and scintigraphic diagnosis: helical CT versus angiography.. Am J Roentgenol 1995; 164: 1369-1374.
14 Velmahos GC, Toutouzas KG, Vassiliu P. et al. Can we rely on computed tomographic scanning to diagnose pulmonary embolism in critically ill surgical patients?. J Trauma 2004; 56: 518-525.
15 Blachere H, Latrabe V, Montaudon M. et al. Pulmonary embolism revealed on helical CT angiography: compasrison with ventilation-perfusion radionuclide lung scanning.. AJR Am J Roentgen 2000; 174: 1041-1047.
16 Blum AG, Delfau F, Grignon B. et al. Spiral computed tomography versus pulmonary angiography in the diagnosis of acute pulmonary embolism.. Am J Cardiol 1994; 74: 96-98.
17 Garg K, Welsh CH, Feyerabend AJ. et al. Pulmonary embolism: diagnosis with spiral CT and ventilation- perfusion scanning--correlation with pulmonary angiographic results or clinical outcome.. Radiology 1998; 208: 201-208.
18 Kim Kun-II, Muller NL, Mayo JR. Clinically suspected pulmonary embolism: utility of spiral CT.. Radiology 1999; 210: 693-697.
19 Mayo JR, Remy-Jardin M, Muller NL. et al. Pulmonary embolism: prospective comparison of spiral CT with ventilation-perfusion scintigraphy.. Radiology 1997; 205: 447-452.
20 Otmani A, Tribouilloy C, Leborgne L. et al. Diagnostic value of echocardiography and thoracic spiral CT angiography in the diagnosis of acute pulmonary embolism.. Ann Cardiol Angeiol (Paris) 1998; 47: 707-715.
21 Pruszczyk P, Torbicki A, Pacho R. et al. Noninvasive diagnosis of suspected severe pulmonary embolism: transesophageal echocardiography vs spiral CT.. Chest. 1997; 112: 722-728.
22 Sostman HD, Layish DT, Tapson VF. et al. Prospective comparison of helical CT and MR imaging in clinically suspected acute pulmonary embolism.. J Magn Reson Imaging 1996; 6: 275-281.
23 Steiner P, Phillips F, Wesner D. et al. Primary diagnosis and follow-up in acute pulmonary embolism: comparison of digital subtraction angiography and spiral CT.. Rofo Fortschr Geb Rontgenstr Neuen Bildgeb Verfahr 1994; 161: 285-291.
24 van Rossum AB, Pattynama PM, Ton ER. et al. Pulmonary embolism: validation of spiral CT angiography in 149 patients.. Radiology 1996; 201: 467-470.
25 Coche E, Verschuren F, Keyeux A. et al. Diagnosis of acute pulmonary embolism in outpatients: comparison of thin-collimation multi-detector row spiral CT and planar ventilation perfusion scintigraphy.. Radiology 2003; 229: 757-765.
26 Winer-Muram HT, Rydberg J, Johnson MS. et al. Suspected acute pulmonary embolism: evaluation with multi-detector row CT versus digital subtraction pulmonary arteriography.. Radiology 2004; 233: 806-815.
27 van Strijen MJ, de Monye W, Schiereck J. et al. Single-detector helical computed tomography as the primary diagnostic test in suspected pulmonary embolism: a multicenter clinical management study of 510 patients.. Ann Intern Med 2003; 138: 307-314.
28 Usman MU, Bari V, Yaqoob J. et al. Diagnosis of pulmonary embolism with helical C.T. scan.. J Pak Med Assoc 2003; 53: 354-356.
29 Senac J-P, Vernhet H, Bousquet C. et al. Embolie pulmonaire: apport de la tomodensitométrie hélicoïdale.. J Radiol 1995; 76: 339-345.
30 Cauvain O, Rémy-Jardin M, Rémy J. et al. Tonodensitométrie par balayage spirale volumique dans le diagnostic de l’embolie pulmonaire centrale: comparison avec l’angiographie pulmonaire et la scintigraphie pulmonaire.. Rev Mal Resp 1996; 13: 141-153.
31 Raptopoulos V, Boiselle PM. Multi-detector row spiral CT pulmonary angiography: comparison with single-detector row spiral CT.. Radiology 2001; 221: 606-613.
32 Patel S, Kazerooni EA, Cascade PN. Pulmonary embolism: optimization of small pulmonary artery visualization at multi-detector row CT.. Radiology 2003; 227: 455-460.
33 Wells PS, Anderson DR, Rodger M. et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer.. Ann Intern Med 2001; 135: 98-107.
34 Eisner MD. Before diagnostic testing for pulmonary embolism: estimating the prior probability of disease.. Am J Med 2003; 114: 232-234.
35 Sackett DL. Bias in analytic research.. J Chronic Dis 1979; 32: 51-63.
36 Coche EE, Hamoir XL, Hammer FD. et al. Using dual-detector helical CT angiography to detect deep venous thrombosis in patients with suspicion of pulmonary embolism: diagnostic value and additional findings.. Am J Roentgenol 2001; 176: 1035-1039.
37 Garg K, Kemp JL, Wojcik D. et al. Thromboembolic disease: comparison of combined CT pulmonary angiography and venography with bilateral leg sonography in 70 patients.. Am J Roentgenol 2000; 175: 997-1001.
38 Loud PA, Katz DS, Bruce DA. et al. Deep venous thrombosis with suspected pulmonary embolism: detection with combined CT venography and pulmonary angiography.. Radiology 2001; 219: 498-502.
39 Nicolas M, Debelle L, Laurent V. et al. Incremental lower extremity CT venography, a simplified approach for the diagnosis of phlebitis in patients with pulmonary embolism.. J Radiol 2001; 82: 251-256.
40 Begemann PG, Bonacker M, Kemper J. et al. Evaluation of the deep venous system in patients with suspected pulmonary embolism with multi-detector CT: a prospective study in comparison to Doppler sonography.. J Comput Assist Tomogr 2003; 27: 399-409.
41 Richman PB, Wood J, Kasper DM. et al. Contribution of indirect computed tomography venography to computed tomography angiography of the chest for the diagnosis of thromboembolic disease in two United States emergency departments.. J Thromb Haemost 2003; 1: 652-657.
42 Revel MP, Petrover D, Hernigou A. et al. Diagnosing pulmonary embolism with four-detector row helical CT: prospective evaluation of 216 outpatients and inpatients.. Radiology 2005; 234: 265-273.
43 Ghaye B, Nchimi A, Noukoua C. et al. Does multidetector row CT pulmonary angiography reduce the incremental value of indirect CT venography compared with single-detector row CT pulmonary angiography?. Radiology 2006; 240: 256-262.
44 Johnson JC, Brown MD, McCullough N. et al. CT lower extremity venography in suspected pulmonary embolism in the ED.. Emerg Radiol 2006; 12: 160-163.
45 Cham MD, Yankelevitz DF, Shaham D. et al. Deep venous thrombosis: detection by using indirect CT venography. The Pulmonary Angiography-Indirect CT Venography Cooperative Group.. Radiology 2000; 216: 744-751.
46 Nchimi A, Ghaye B, Noukoua CT. et al. Incidence and distribution of lower extremity deep venous thrombosis at indirect computed tomography venography in patients suspected of pulmonary embolism.. Thromb Haemost. 2007; 97: 566-572.
47 Wittram C, Maher MM, Yoo AJ. et al. CT angiography of pulmonary embolism: diagnostic criteria and causes of misdiagnosis.. RadioGraphics 2004; 24: 1219-1238.
48 Wells PS, Ginsberg JS, Anderson DR. et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism.. Ann Intern Med 1998; 129: 997-1005.
49 Sanson BJ, Lijmer JG, Mac Gillavry MR. et al. Comparison of a clinical probability estimate and two clinical models in patients with suspected pulmonary embolism. ANTELOPE-Study Group.. Thromb Haemost 2000; 83: 199-203.
50 Wells PS, Anderson DR, Rodger M. et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-Dimer.. Thromb Haemost 2000; 83: 416-420.
51 Chagnon I, Bounameaux H, Aujesky D. et al. Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism.. Am J Med 2002; 113: 269-275.
52 Wicki J, Perneger TV, Junod AF. et al. Assessing clinical probability of pulmonary embolism in the emergency ward. A simple score.. Arch Intern Med 2001; 161: 92-97.
53 Le Gal G, Righini M, Roy PM. et al. Prediction of pulmonary embolism in the emergency department: the revised Geneva score.. Ann Intern Med 2006; 144: 165-171.
54 A Collaborative Study by the PIOPED Investigators.. Value of the ventilation/perfusion scan in acute pulmonary embolism: Results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED).. J Am Med Assoc 1990; 263: 2753-2759.
55 Stein PD, Woodard PK, Weg JG. et al. Diagnostic pathways in acute pulmonary embolism: Recommendations of the PIOPED II investigators.. Am J Med 2006; 119: 1048-1055.
56 Le Gal G, Righini M, Sanchez O. et al. A positive compression ultrasonography of the lower limb veins is highly predictive of pulmonary embolism on computed tomography in suspected patients.. Thromb Haemost 2006; 95: 963-966.
57 Elias A, Cazanave A, Elias M. et al. Diagnostic management of pulmonary embolism using clinical assessment, plasma D-dimer assay, complete lower limb venous ultrasound and helical computed tomography of pulmonary arteries. A multicentre clinical outcome study.. Thromb Haemost 2005; 93: 982-988.
58 Grebe MT. Combined computed tomographic (CT)-angiography and indirect CT-venography for the diagnosis of pulmonary embolism: is more scanning better?. Thromb Haemost 2007; 97: 501-502.
59 Johnson TR, Nikolaou K, Wintersperger BJ. et al. ECG-gated 64-MDCT angiography in the differential diagnosis of acute chest pain.. Am J Roentgenol 2007; 188: 76-82.
60 Savino G, Herzog C, Costello P. et al. 64 slice cardiovascular CT in the Emergency Department: concepts and first experiences. Radiol Med (Torino) 2006; 111: 481-496.
61 Remy-Jardin M, Tillie-Leblond I, Szapiro D. et al. CT angiography of pulmonary embolism in patients with underlying respiratory disease; impact of multislice CT on image quality and negative predictive value. Eur Radiol 2002; 12: 1971-1978.
62 Kavanagh EC, O’Hare A, Hargaden G. et al. Risk of pulmonary embolism after negative MDCT pulmonary angiography findings. Am J Roentgenol 2004; 182: 499-504.
63 Perrier A, Roy PM, Aujesky D. et al. Diagnosing pulmonary embolism in out patients with clinical assessment, D-dimer measurement, venous ultrasound, and helical computed tomography: amulticenter management study. Am J Med 2004; 116: 291-299.
64 Perrier A, Roy PM, Sanchez O. et al. Multi-row computed tomography in suspected pulmonary embolism. N Eng J Med 2005; 352: 1760-1768.
65 Prologo JD, Gilkeson RC, Diaz M. et al. The effect of single-detector CT versus MDCT on clinical outcomes in patients with suspected acute pulmonary embolism and negative results on CT pulmonaryangiography. Am J Roentgenol 2005; 184: 1231-1235.
66 van Belle A, Buller HR, Huisman MV. et al. for the Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolismusing an algorithmcombining clinical probability, D-dimertesting, and computed tomography. J Am Med Assoc 2006; 295: 172-179.
67 Stein PD, Beemath A, Goodman LR. et al. Outcome studies of pulmonary embolismversus accuracy: They do not equate. Thromb Haemost 2006; 96: 107-108.